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Comment by daveloyall | Hacker News Reader

Hello. I work for public health. My job is to support the computer systems that allow epidemiologists to track 'superbugs' (and regular ones).

Deathcerts is an interesting dataset. It's not the only one.

Even if death-by-MSRA isn't tracked, I assure you that MSRA itself is tracked.

There's a specific class of lab test called "antibiotic susceptibilities". The results report includes a bunch of numbers that represent just HOW resistant a particular bug is to a standard battery of antibiotics, broken down per antibiotic.

That data is transmitted from the labs that performed the test to the state health department where it is analyzed.

Fascinating article, but there's NO WAY that Reuters had that much contact with state public health folks without being aware that they track lab results. Misleading!

Edit: elaborated about the susceptibilities results.

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Fascinating article, but there's NO WAY that Reuters had that much contact with state public health folks without being aware that they track lab results. Misleading!

This shouldn't be surprising. Imagine if Reuters wrote an article that said:

- Everyone acknowledges that superbugs are an issue

- Hospitals are doing their best with their limited resources, but overall are capturing a good deal of data

- The data systems are old, but the CDC can get the data and with some manual work process it, but it takes time

- Everyone agrees that more could be done, but they also agree it's complex and nothing is perfect.

No one would read the article!!

From the subhead: "government agencies remain unwilling or unable to impose reporting requirements on a healthcare industry that often hides the problem"

I ask as someone who is quite a novice when it comes to knowledge of what is the expected reporting requirement: That subhead is a blanket assertion, but when applied to the death-by-MRSA issue, do the public have access to accurate, up-to-date information? If not, isn't that assertion partially correct?

OK, so somebody's tracking it in secret, doing the 'antibiotic susceptibilities' tests and logging the results, and the state health dept receives the data, but the info is being kept from the patients' relatives and from the public in general?

This creates two obvious results. 1) suppression of legitimate claims from relatives, and 2) suppression of valid concern and pressure for govt action such as increased research funding.

How is this good?

In particular, a potential patient might want to know MRSA case rates when selecting hospitals or other medical treatment facilities.

Or (perhaps more likely) Medicare/Medicaid and/or private insurers might start penalizing the ones that are screwing it up (by renegotiating contracts and reimbursements). I know of one center where executive laziness led to a $2 million fine (completely unjustified) for a line infection in an immunosuppressed patient. Which was cleared up in hours, probably didn't come from the line to begin with, and got said executive fired (because if there's one thing hospital "leadership" understands, it's money).

Actually I have all sorts of examples of the above, but the point is that oftentimes the data is "corrupted" on the way to the collection point(s). Anyways, the executive (VP of some bullshit) got his walking papers and funnily enough, no more reportable line infections that didn't come from lines.

So at least sometimes there are happy endings, sort of...

Sorry, I am a little confused. Why was it a happy ending? Because the VP was just a titular post? Also, looking at your comment, it reads like the problem went away not because the hospital improved, but because the data stopped being reported. This does not look like a happy ending either. And if the line infection was cleared up in hours, how did it also "probably didn't come from the line to begin with"?

The VP was a douche and the "line infection" was almost certainly not from a line in the first place. The patient was on IST, so calling any random opportunistic infection a central line infection is (at best) irresponsible.

Reporting incorrect data can be worse than reporting nothing at all. Here are the guidelines: http://www.cdc.gov/nhsn/pdfs/faqs/faqs-v-6_clabsi.pdf

CLIs are only supposed to be reported when the central line can reasonably be implicated as the vector and the blood is the primary infection site. Neither was established.

As far as cleaning up procedures, there will always be room for further improvement, but that's no reason to accept a $2 million fine (which still had to be paid) as a cost of doing business when the "root cause" was incorrect reporting.

I'm not saying it is good. I'm just saying that there is more than one thing going on here.

I don't think hospitals have any motivation to hide antibiotic-resistant infections ("superbugs") specifically. HOWEVER, the motive to hide hospital-acquired infections[0] is clear!

Here's some mud in the water: what's the difference between a HAI with some bug that is easily killed by antibiotics vs. an antibiotic resistant bug?

As for "tracking it in secret", that's one way to put it, but it will cloud your thinking. :) Your own medical records--specifically blood test lab results--have your name, address, and phone number on them. Consider replacing the word 'secret' with 'private' and re-working the whole thought.

0: http://www.cdc.gov/hai/

Yes, I totally get privacy, and I'm glad to read that you're not saying it is good.

It's the hiding it in public records such as Death Certificates, information given to the family, and performance statistics that I find suspicious.

You start out by saying that the article is "misleading", and that MRSA is tracked. The article is pretty convincing that it's not accurately reported.

Then you agree with the article that "the motive to hide hospital-acquired infections is clear".

Uhh... That's kind of a huge problem.

Yes, as the article points out:

> There’s also a powerful incentive not to mention a hospital-acquired infection: Counting deaths is tantamount to documenting your own failures. By acknowledging such infections, hospitals and medical professionals risk potentially costly legal liability, loss of insurance reimbursements and public-relations damage.

Well yeah. But hey, I'm no journalist.

I stand by my assertion that nobody is trying to "hide" the "superbug" problem.

The human tendency to not self-report failures is a thing. But it's not some kind of biohazard conspiracy.

And one more thing about the death certificates...

    > In a statement emailed to Reuters, Frieden said: 
    > "While death certificates provide helpful 
    > information, the unfortunate reality is that they
    > don't provide in-depth clinical information."

I'm guessing that Frieden, the boss of the whole CDC, went on to say something like: "But it makes sense, because death certificates are primarily legal records. The clinical information lives in medical records." OR, OR, something more accurate. That's why he gets the big bucks. :)

Well, you know more about this space than I do. So maybe it's not so bad...

But the article sure makes it sound like hospitals are hiding MRSA-related deaths, since MRSA infections are often "hospital acquired". And we all agree that hospitals would have an incentive to hide these numbers.

And the apparent under-reporting seems to indicate that this is in fact what's going on. This sounds like a problem! Thanks a lot, dishonest hospitals!

Daveloyall is correct. I'll add that pretty much every local hospital system has their own database of antibiotic susceptibilities that is updated regularly so that doctors can prescribe the best antibiotic for the microbe populations specific to their region. Pretty nifty.

If you are curious as to what this might look like, here is the University of Washington 'antibiogram' for 2015:

http://depts.washington.edu/labweb/Divisions/Micro/antibiogr...

Strange, so that basically refutes the a pretty core point of the article (that it isn't being tracked).

The reason they said doctors don't put it on death records is because they dont always want to wait the 2-3 days it takes to get results back from the labs. So it makes way more sense that the labs record the bugs. Instead of doctors in the field.

Those are the people who are trained to detect the bugs... so they should be responsible for tracking them. I presume they could get indications from the doctors on whether the patients died as well.

Couldn't the doctors update death records after-the-fact? If they found out afterwards what the actual cause of death was, they should really being recording that.

Update... I asked around the office and learned more about this. TL;DR: I'm less right than I thought.

Specifically regarding tracking cause of death:

Not every disease or condition is "reportable". Each state maintains a list of reportable diseases. When a hospital/lab (hereafter: facility) encounters a disease on the list, then they are required to report it.

State health departments will open investigations in various circumstances. You've seen events like e. coli outbreaks in the news--those always precipitate an investigation. There are also investigations associated with individual infections, i.e. every case of tuberculosis.

If a patient involved in an investigation dies, public health will find out.

But, if a patient dies from (because of) an infection that wasn't on the reportable list, then public health won't know the cause of death unless it is on the death certificate. Just like the article says!

Regarding tracking the susceptibility of bacteria to antibiotics (superbugs):

Any sample that is tested for antibiotic susceptibility is reportable. The results of that testing generally include the specimen source, but don't include why the test was ordered (i.e. because some person has sepsis and might die) and certainly there's no (deliberate) relation between this data and cause of death.

>>but there's NO WAY that Reuters had that much contact with state public health folks

Why Not? They said it was a YEAR LONG investigation...

Read that sentence again. It makes an argument that hinges upon Reuters having had a lot of contact.

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